Remote Pre Authorization Nurse, Multiple Locations

Humana

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Location: KY
Location Type: Remote
Additional Location: AL; AZ; AR; CO; CT; DE; FL; GA; ID; IL; IN; IA; KS; LA; ME; MD; MA; MI; MN; MS; MO; MT; NE; NV; NH; NJ; NM; NY; NC; ND; OH; OK; PA; RI; SC; SD; TN; TX; UT; VT; VA; WV; WI; WY;
Schedule: Full_time
Req: R-340560

Become a part of our caring community and help us put health first

The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves services or forward requests to the appropriate stakeholder. The Pre-Authorization Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

 

Coordinate care for MHS beneficiaries receiving care outside the MTF. Monitor quality of care, identify, and document any potential quality issues regarding the patient’s care. Coordinate patient transfers and document appropriately in MSR. Review inpatient outlier cases, ensure appropriate and timely discharge planning, and refer to Tier III care management as needed.
Key Accountabilities –

  • Perform prior authorization reviews according to established HUMANA GOVERNMENT BUSINESS contractual requirements and guidelines to include timely data entry in MSR.
  • Perform accurate and timely assessment and concurrent review of outlier admissions using InterQual criteria and document review results in MSR. Pend cases appropriately to second level review and follow up with any denial activities as indicated.
  • Complete and document in MSR accurate and timely determinations of appropriateness of level of care: take appropriate actions to facilitate direction of patients to correct level of care as indicated by criteria.
  • Direct discharge planning appropriately; Maximize steerage of patients to the MTFs and preferred providers; Facilitate move to alternative levels of care in a timely manner.
  • Identify and follow patients requiring Tier II Care Management. Coordinate cases with and refer to tier III Care Manager and Disease Management Programs as appropriate.

Use your skills to make an impact

Required Qualifications

  • Our Department of Defense Contract requires U.S. citizenship for this position
  • Successfully receive interim approval for government security clearance (eQIP – Electronic Questionnaire for Investigation Processing)
  • Registered Nurse with current in-state RN license
  • At least 3 years of varied clinical RN nursing experience
  • Computer skills, including data entry
  • Proficient with MS Office products including Word, Excel and Outlook

Preferred Qualifications

  • Utilization Review/Quality Management experience
  • BA/BSN degree
  • TRICARE experience
  • Interqual Criteria/MCG experience

Work-At-Home Requirements

 

To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:

  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
  • Satellite, cellular and microwave connection can be used only if approved by leadership
  • Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
  • Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
  • Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

 

Scheduled Weekly Hours

 

40

 

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$69,800 – $96,200 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

 

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

 

Equal Opportunity Employer

 

It is the policy of  Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.